• Are there validated, evidence-informed decision support tools that address the clinical decision? If not, does the available evidence provide enough certainty about the estimates of the intervention’s effects to confidently relay the information to patients?

• Does there appear to be unwarranted variation in the use of the intervention?

Many, if not most, health care decisions could be improved through the use of patient decision support tools. The Institutes of Medicine (2014) emphasizes the broad applicability of patient decision support tools:

There are a few treatment decisions, such as whether to set a broken arm, for which there is such incontrovertible evidence of benefit and so few downsides, that clinicians and patients would be almost unanimous about what to do. While some have sought to limit the application of shared decision making to preference-sensitive decisions, this distinction is difficult to define and challenging to apply in practice.We propose that the default position for every medical decision for which the options or results have health, financial, or quality-of-life implications should be that patients should be informed about their options and given a chance to have their informed choices honored when decisions are made. In particular, since patients must implement (and could in the process revise) many health care decisions—to fill prescriptions, attend visits, self-monitor blood sugars—SDM should be the aim for discrete decisions (such as whether to receive a certain screening test, or which treatment option to pursue for a given diagnosis) and also for ongoing, daily management and lifestyle choices for such chronic conditions as diabetes or high blood pressure.

In practice, decisions must be made about which topics should be prioritized for the selection and implementation of patient decision support tools. The following questions may be considered by those tasked with choosing topics for patient decision support tools implementation.

Ethical Considerations

Little has been written about ethical considerations in the use of patient decision support tools. In general, decision support tools are thought to promote patient-centered care and autonomy.Brehaut and colleagues (2010) suggest that shared decision making may help alleviate concerns about inadequate informed consent processes. Washington State has even established shared decision making as an alternative to traditional informed consent in statute (Revised Code of Washington, Section 7.70.065).

However, there is a possibility that decision support tools can be expressly designed to lead patients toward a decision deemed desirable by actors other than the patient. Such “nudges” or “libertarian paternalist” approaches have been advocated in the creation of decision aids for PSA screening for prostate cancer (Wheeler, et al, 2011) and in other clinical situations including colorectal cancer screening and treatment of deep vein thrombosis (Blumenthal-Barby, et al, 2013). There is active debate about the ethics of using decision aids to lead patients toward pre-selected choices, but standards promulgated by the International Patient Decision Aids Standards Collaboration emphasize that decision support tools should offer balanced, unbiased interpretations of systematically summarized data and non-judgmental elicitation of patient values and preferences. At a minimum, those involved in the creation and use of decision support tools must disclose any conflicts of interest.